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CP4 > final from quizlet > Flashcards

final from quizlet Flashcards

1
Q

primary intention healing

A

primary intention healing
wound edges are well approximated with minimal to no tissue loss

“hairline” scar

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2
Q

secondary intention

A

wound edges are unable to be easily approximated, typically a gaping wound with significant tissue loss

leaves a large scar

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3
Q

pressure ulcer etiology

A

unrelieved pressure resulting in disrupted blood supply to an area

(friction, shear, supply and moisture)

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4
Q

venous insufficiency

A

inability of the veins to adequately return blood from the lower extremities

(blood pooling & edema)

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5
Q

surgical dehiscence

A

opening of previously closed wound

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6
Q

what contributes to the development of wounds

A
  1. pressure INTENSITY
  2. pressure DURATION
  3. tissue TOLERANCE
  • know the cause to prevent recurrence
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7
Q

stage 1 pressure injury

A

non-blanchable erythema of intact skin

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8
Q

stage 2 pressure injury

A

partial thickness tissue loss showing pink or red viable tissue, moist, with a distinct wound margin

slough/eschar NOT present

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9
Q

stage 3 pressure injury

A

full thickness tissue loss with just subcutaneous adipose tissue layer exposed

slough/eschar present

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10
Q

stage 4 pressure injury

A

full thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone

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11
Q

unstageable pressure injury

A

dry, stable eschar firm cap OR moist, boggy eschar cap

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12
Q

deep tissue injury

A

dusky, boggy or discoloured area of purple, maroon, ecchymosis or a blood-filled blister

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13
Q

what does the Braden Scale assess?

A

pressure sore risk

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14
Q

full thickness wound repair phases

A
  1. INFLAMMATORY PHASE : hemostasis, clots form, mast cells secrete histamine
  2. PROLIFERATIVE PHASE : new blood vessel appear, fill with granulation tissue, fibroblasts synthesize collagen
  3. REMODELING : maturation, can take up to 2 years
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15
Q

how do you measure a wound?

A

length x width x depth

sinus tract (narrow channel or passageway) and measure using a clock format (pts head is 12:00)

undermining (open area extending under intact skin along edge of wound

ALL IN CM

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16
Q

wound irrigation

A

flushing of an open wound using a solution such as sterile saline or sterile water

30-35 cc syringe with wound irrigation tip

use approximately 100 cc to flush wound bed or until solution runs clear

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17
Q

what is the purpose of wound packing?

A

to loosely fill dead spaces

facilitate the removal of exudate and debris

encourage the growth of granulation tissue from base of wound to present premature closure and abscess formation

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18
Q

complications of over packing a wound

A

will cause pressure on wound tissue that can cause pain, impair blood flow and further damage

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19
Q

complications of under packing a wound

A

may result in rolled wound edges and/or abscess formation

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20
Q

peri-wound skin

A

skin around the wound

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21
Q

indications for indwelling catheters?

A
  1. urinary retention
  2. short-term monitoring of urinary output
  3. peri-op and intra-op monitoring of output
  4. facilitate healing of pressure ulcers in incontinent pts
  5. requires prolonged immobilization
  6. improve comfort (end of life care)
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22
Q

what are in and out catheters used for?

A

single lumen foley

used for short-term use, does not remain in the bladder

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23
Q

what are two way foley catheters used for?

A

double lumen foley

used longer term, balloon inflates and it remains in the bladder

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24
Q

what is a three-way foley catheter used for?

A

triple-lumen foley

used for bladder irrigation

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25
Q

what is a coude catheter used for?

A

used when there are difficult insertions such as a pt with BPH

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26
Q

what position is best for patients when inserting a foley catheter?

A

male: supine and legs extended
female: dorsal recumbent

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27
Q

once urine starts flowing out of the catheter, how much further do you insert before inflating the balloon?

A

2.5-5cm

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28
Q

how can you present a CAUTI?

A
  • proper peri-care pre insertion
  • maintain aseptic technique
  • sterility of insertion
  • promote a one-way flow of urine (stat lock in place, bag below bladder and above floor)
  • new drainage container every 24 hrs
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29
Q

what order do you put in a foley catheter?

A
  1. clean gloves to perform peri-care
  2. hand hygiene
  3. open foley kit, position drape under the buttocks
  4. drop foley onto the sterile field
  5. pour antiseptic solution into the container of cotton balls
  6. don sterile gloves
  7. lubricate catheter
  8. drape over the perineum
  9. place sterile contents on the drape
  10. cleanse the meatus
  11. insert catheter
  12. inflate balloon
  13. pull gently until resistance is felt
  14. attach drainage end of the catheter to collecting tubing
  15. secure catheter using stat-lock
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30
Q

what is closed bladder irrigation used for?

A

prevent or remove clots post-surgery in the urinary system

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31
Q

what instructions would you give to a patient after a foley removal?

A
  1. increase fluid intake
  2. need to void within 6-8 hrs post removal
  3. measure first void
  4. some irritation may be present upon first void
  5. try to empty bladder fully
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32
Q

what is a nasogastric tube?

A

tube inserted through one of the nostrils, down the nasopharynx, down the esophagus and into the stomach

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33
Q

what is an NG tube used for?

A

(large bore tube: salem sump)

used for gastric decompression (draining the stomach) & medications

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34
Q

what are EN tubes used for?

A

(small bore tube)

used for feeding & medications

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35
Q

what should you assess prior to inserting an NG tube?

A
  • indication
  • hx of facial trauma/basal skull fractures
  • esophageal varices
  • deviated septum
  • coagulation studies
  • visual assessment of patency of nares
  • GI assessment
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36
Q

how do you determine the length of an NG tube for insertion?

A

measure from the tip of the nose, to the earlobe, to the tip of the xiphoid process

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37
Q

how do we determine the correct placement of the NG tube?

A
  1. withdraw gastric contents and test the pH
  2. chest x-ray
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38
Q

what should the pH of the gastric contents be?

A

1.5-5 (if greater than 6 it is likely from the lungs)

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39
Q

ongoing NG tube care/management

A
  1. pH check
  2. external measurement check
  3. inspection of nostrils (eg. irritation, adhesion of tape)
  4. resp assessment
  5. GI assessment
  6. mouthcare
  7. connection to suction (as per dr’s orders)
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40
Q

what should you do if a pt starts coughing during the NG tube insertion?

A

remove and try again

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41
Q

what should you do if a pt is uncomfortable during the NG tube insertion?

A

you can ask them to swallow, give them a cup of water and a straw to sip on during the insertion

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42
Q

where is the nasoenteric tube placed & why?

A

duodenum, reduces aspiration risk

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43
Q

what position should the pt be in for insertion of an EN tube?

A

High Fowlers

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44
Q

possible complications of enteric feeds

A
  • tube placement
  • tube occlusion
  • abdominal cramping, nausea, vomiting
  • diarrhea
  • pulmonary aspiration
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45
Q

how can you prevent pulmonary aspiration?

A
  • sit straight up when tube feeding
  • keep the head of the bed at least 30 degrees
  • perform oral care routinely
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46
Q

describe the process of flushing meds through an EN tube

A
  1. flush with 30 cc’s of water before meds
  2. mix each med with 15 - 30 cc’s
  3. admin the med
  4. flush with 30 cc’s between all meds
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47
Q

what are the two system types for feeding solutions?

A
  1. OPEN: pour solution into a bag and prime tubing
  2. CLOSED: prepared bag which you spike with tubing
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48
Q

what frequency types may be used for feeding?

A
  1. INTERMITTENT
  2. CONTINUOUS
  3. SYRINGE (infants)
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49
Q

gastrojejunal (GJ) tubes

A

used long-term

inserted surgically

port is outside of the body, into the stomach, tube goes down into the jejunum

prevents aspiration risk d/t placement

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50
Q

ostomy

A

surgical procedure resulting in the external diversion of feces or urine through an abdominal stoma

can be temporary or permanent

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51
Q

ileostomy

A

opening in the ileum, typically in the RLQ

creates looser stools

52
Q

urostomy

A

small piece of ileum is attached to the ureters and stoma is brought out

53
Q

nephrostomy

A

tube placed directly into the renal pelvis to drain urine

54
Q

loop ileostomy

A

proximal and distal opening

usually temporary

may have a rod post-op

55
Q

end ileostomy

A

initially sutured, sutures should fall out on their own

56
Q

what is the normal ileostomy output

A

500-750 mLs daily (depending on intake)

toothpaste to oatmeal consistency

57
Q

are laxatives, suppositories or enemas recommended for ileostomy’s?

A

NO

stool is usually too liquid, stoma has no sphincter to allow for suppository retention

58
Q

when should you empty the ileostomy bag and how often per day?

A

empty when 1/3-1/2 full

important as the enzymes contained in the liquid stool can damage the peri-stomal skin

typically 4-6x per day

59
Q

what type of diet should a patient with a recent ileostomy be on?

A

low fibre diet

extra fluids and electrolytes due to higher fluid loss

60
Q

pt education on partial/complete ileostomy obstruction

A

there is a risk for food blockage

SYMPTOMS:
no output or high liquid output in 12 hrs
cramping, bloating, nausea

MANAGEMENT:
go to emergency

61
Q

colostomy

A

opening in the colon, typically in the LLQ (descending colon)

creates more solid stools

62
Q

colostomy dietary considerations

A

no need for specific changes, recommend a balanced diet

HOWEVER

some foods may increase gas or odour (broccoli, cauliflower, cabbage, brussel sprouts)

if gas is a problem avoid (talking while eating, carbonated beverages, drinking through straws)

63
Q

what foods may help thicken stoma output?

A

yogurt, cheese, white bread, potatoes, pasta, bananas, pasta, white rice, applesauce

64
Q

is there a change in medication absorption with colostomies

A

NO

65
Q

normal output for colostomies

A

1-3 movements daily

semi-formed to formed

66
Q

ileostomy/colostomy reversal

A

minimum 3 months after initial surgery

some diarrhea is normal after reversal

67
Q

normal output for urostomies

A

1000-2000 mLs daily

yellow with mucous shreds

68
Q

what does the ideal stoma look like?

A

2.5 cm tall

red/pink, moist, round

smooth surface below belt line

69
Q

describe the process of changing an ostomy pouch

A
  1. empty pouch
  2. position client
  3. remove old appliance
  4. clean (only warm water)
  5. measure stoma
  6. cut pattern
  7. remove film from flange and secure over stoma
  8. attach pouch
70
Q

chemical damage of peri-stomal skin

A

due to output in contact with skin

change appliance, powder and no-sting spray to help heal areas

71
Q

mechanical damage of peri-stomal skin

A

due to inappropriate removal or flange/tape

teach a traumatic appliance removal and teach gentle skin care

72
Q

fungal rash damage to peri-stomal skin

A

due to persistent skin moisture or abx use

keep skin try and topical antifungal powder & sealant as indicated

73
Q

pseudoverrucous lesions to peri-stomal skin

A

chronic exposure to urine or moisture, creates lesions

ensure a correctly fitting appliance, consider extended wear barrier

74
Q

pyoderma gangrenosum to peri-stomal skin

A

dysregulation of immune system, 3 P’s (pain, purple, pus)

non-tramatic wound care, topical steroids, systemic steroids

75
Q

mucocutaneous separation

A

breakdown of suture line securing the stoma to abdominal surface

management is conservative wound care

76
Q

prolapse stoma

A

due to excessively large opening in abdominal wall or increased abdominal pressure

modify pouch to accommodate the wider diameter & increased length of stoma

may require surgical intervention

77
Q

peristomal hernia

A

protrusion of bowel into subcutaneous tissue

hernia belt, flexible flange

78
Q

flush/retracted stomas

A

insufficient stomal length

treat with belts or rings, or surgical revision when indicated

79
Q

what do you do if a stoma is located in a crease/fold?

A

fill the creases for flat adhesion or use of a belt

80
Q

S&S associated with hypoxia and hypercapnia

A
  • Low O2 sats
  • tachycardic, hypertensive, tachypneic
  • anxiety
  • decreased LOC & ability to concentrate
  • lethargy
  • dizziness
  • pallor/cyanosis
81
Q

oropharyngeal suctioning

A

removal of secretions from the throat with a Yankauer suction catheter through the mouth

encourage client to cough, rinse with water

82
Q

nasopharyngeal and nasotracheal suctioning indications

A
  1. to maintain a patent airway and remove saliva, pulmonary secretions, blood, vomit, or foreign material from trachea
  2. to stimulate cough
  3. to obtain a sputum sample for lab analysis
83
Q

what position should a pt be in before suctioning

A

Semi-Fowlers or sitting upright

84
Q

what rate should the suction be set at when doing nasotracheal/pharyngeal suctioning?

A

80-100

85
Q

describe the process of nasotracheal suctioning

A
  1. attach to wall suction (80-100 mmHg)
  2. lubricate the end, insert into the nares approx 20 cm WITHOUT suctioning
  3. intermittent suction and rotate catheter upon removal for 10-15 seconds
  4. flush with sterile NS/water
  5. re-apply oxygen to oxygenate, wait 1 minute if another pass is required, limit to 2 passess
86
Q

blood component

A

therapeutic component of blood (eg. RBCs, platelets, plasma and cryoprecipitate)

87
Q

blood product

A

any therapeutic product derived from human blood or plasma and produced by a manufacturing process (eg. albumin, immunoglobulin preparations, and coagulation factors)

88
Q

what is the shelf life of blood

A

35-42 days

89
Q

when is consent NOT required prior to a blood transfusion?

A

when urgent treatment is necessary to preserve a patient’s life and continuing health and it is not reasonably possible to obtain consent, and there is not substitute decision maker

90
Q

what should be included in the blood product order

A
  1. number of units or volume in mLs required
  2. rate or duration of the infusion
  3. special requirements
91
Q

what IV gauge is recommended for blood product transfusion?

A

18-20 gauge (can use 22)

large enough to allow flow rate and avoid cell damage

92
Q

pre-transfusion patient assessment

A

within 30 mins of transfusion, BEFORE spiking blood product

looking for any clinical manifestations that may delay transfusion or may be confused with a transfusion reaction (eg. fever or pre-existing rash)

record baseline vital signs, chest auscultation and review of fluid balance for high risk patients

93
Q

what administration set is used for blood infusions?

A

blood infusion set with micron filter to administer RBCs, platelets, plasma and cryoprecipitate

94
Q

what administration set is used to administer IVIG and albumin?

A

primary infusion set

95
Q

what solution is compatible with blood?

A

NS

96
Q

what other assessments do you need to complete prior to a transfusion?

A
  1. visually inspect blood product for leaks, abnormal color, excessive air or bubbles, evidence of hemolysis, clots or clumping
  2. verify consent
  3. check blood product order
  4. patient and product checking procedure as per agency policy
97
Q

how soon after removing the blood product from temp controlled storage should you administer?

A

within 20 minutes

98
Q

what rate should you administer a blood product at?

A

1ml/kg/hr up to a max of 50 ml/hr for the first 15 minutes

if no s/s or a transfusion reaction occur during the first 15 minutes then adjust the flow rate

99
Q

patient monitoring during a blood transfusion

A

directly observe pt for 15 minutes for s/s of a transfusion reaction

record vital signs (15 min after start, 60 mins after start, and hourly)

100
Q

how long is a blood tubing set good for?

A

2 units, or 4 hours

101
Q

what are s/s of a transfusion reaction

A

fever, hypotension, rigors, anxiety, chest pain, nausea/vomiting, dyspnea, tachycardia/arrhythmias, flushing, rash, urticaria, hypothermia, headache/muscle pain

102
Q

acute hemolytic reaction

A

develops within the first 15 mins
s/s are: chills, fever, lower back pain, tachycardia, tachypnea, and hypotension

103
Q

febrile, non-hemolytic transfusion reaction

A

caused by cytokines released from blood donor WBCs

s/s: fever/and or chills during or up to 4 hours post-transfusion

104
Q

mild allergic transfusion reaction

A

hypersensitivity to plasma proteins

s/s: flushing, itching, hives

105
Q

anaphylactic transfusion reactions

A

more severe than a mild allergic reaction

antibody-antigen reaction

106
Q

circulatory overload transfusion reaction

A

Transfusion too large causing hypervolemia

s/s: coughing, cyanosis, difficulty breathing

107
Q

sepsis transfusion reaction

A

caused by a bacteria or bacterial byproducts which may contaminate blood

108
Q

nursing interventions for a suspected transfusion reaction

A
  1. STOP transfusion, do NOT admin remaining blood in the line
  2. administer 0.9% NS
  3. vital signs, seek help
  4. reconfirm pt identifiers and blood product
  5. call blood lab immediately if an error occurred
  6. administer resuscitative care
  7. report suspected reaction
109
Q

what to do when the transfusion is completed?

A
  1. STOP when bag is empty
  2. flush administration set with 0.9% NS
  3. disconnect line
  4. record VS within one hour of completion
  5. perform post-transfusion blood work if ordered
  6. continue to observe for s/s of transfusion reaction
  7. document
110
Q

what is a tracheostomy tube

A

surgical incision in the trachea below the larynx

4-10 mm tube inserted through stoma into trachea

111
Q

what complications are associated with tracheal suctioning?

A

hypoxemia, cardiac arrhythmias, atelectasis, mucosal trauma, infection, increased intracranial pressure, laryngospasm, aspiration

112
Q

why are trach pts more prone to lung infections?

A

by bypassing all functions of the upper airway the nose doesn’t filter, humidify, and warm the air before entering the lungs

113
Q

why is suctioning done prior to performing trach care?

A

to remove secretions to not occlude the outer cannula when the inner cannula is removed, decrease the risk of airway being blocked by secretions

114
Q

what signs and symptoms indicate a need for tracheostomy suctioning?

A

low O2 sats, cyanosis/pallor, tachypnea, restless/anxious, gurgling voice, crackles/gargles in the upper airway

115
Q

indications for tracheal suctioning

A
  • improve respiratory status
  • maintain a patent airway
  • prevent infection caused by retained secretions
116
Q

what pressure is tracheostomy suctioning done at?

A

80-120

117
Q

describe the process of tracheal suctioning

A
  1. sterile glove in dominant hand guides the suction catheter and non dominant remains non-sterile
  2. insert into the trach until you meet resistance at the bifurcation of trachea then withdraw 1 cm BEFORE starting intermittent suctioning
  3. NO SUCTION when inserting
  4. MAX 10 seconds from insertion to withdrawal, max 2 times with 1 min of hyperoxygenation in between
118
Q

complications of suctioning

A
  1. hypoxemia/hypoxia
  2. atelectasis
  3. mucosal damage
  4. infection
119
Q

what is involved in tracheostomy care?

A

changing the inner cannula and dressing/tube tie change

120
Q

how often do you perform tracheostomy care?

A

q12 PRN

121
Q

how do you calculate a safe pediatric dose with the body weight method?

A
  1. convert child’s weight from pounds to kilograms (1lb = 2.2kg) [ROUND TO TENTHS]
  2. multiply mg/kg by the child’s weight in kg to get the maximum and minimum recommended dose
  3. compare the ordered dose to recommended dose and decide if it is safe
  4. determine the dose (D/H xQ = __ )
122
Q

indications for use of restraints

A

pacing/wandering, unsafe mobility, impaired safety awareness, unable to follow instructions, imminent danger to self or others, pulling tubes/lines/wires etc..

123
Q

alternatives to restraints

A

reorienting, 1:1 added care, repositioning, distracting, de-stimulate the environment, simple statements, basic needs, assess pain, cover IV lines etc..

124
Q

what is the least restraint policy

A

use all possible alternatives and restrain only if necessary for the shortest amount of time

125
Q

what do you document after tracheostomy care?

A
  1. amount, consistency and color of secretions
  2. number of suction attempts
  3. respiratory and cardiopulmonary status pre and post procedure
  4. skin color if indicated
  5. how pt tolerated procedure
126
Q
A

CP4 (4 decks)

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